|
IMPLT POL TRIA 4.8 X 22
|
Facility
|
OP
|
$782.00
|
|
|
Service Code
|
CPT C2617
|
| Hospital Charge Code |
7006795
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$195.50 |
| Max. Negotiated Rate |
$742.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$469.20
|
| Rate for Payer: Cash Price |
$469.20
|
| Rate for Payer: Cash Price |
$469.20
|
| Rate for Payer: Cigna Commercial |
$664.70
|
| Rate for Payer: First Health Commercial |
$703.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$703.80
|
| Rate for Payer: GEHA Commercial |
$625.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$703.80
|
| Rate for Payer: Humana ChoiceCare |
$203.32
|
| Rate for Payer: Multiplan All |
$711.62
|
| Rate for Payer: New Mexico Health Connections Medicare |
$469.20
|
| Rate for Payer: OMNI Networks Commercial |
$547.40
|
| Rate for Payer: One Health Plan PPO/POS |
$703.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$742.90
|
| Rate for Payer: Three Rivers Provider Network All |
$586.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$688.16
|
| Rate for Payer: United Healthcare Managed Medicaid |
$195.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$727.26
|
| Rate for Payer: Zelis Auto |
$312.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$391.00
|
|
|
IMPLT POL TRIA 4.8 X 22
|
Facility
|
IP
|
$782.00
|
|
|
Service Code
|
CPT C2617
|
| Hospital Charge Code |
7006795
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$312.80 |
| Max. Negotiated Rate |
$742.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$625.60
|
| Rate for Payer: Cash Price |
$469.20
|
| Rate for Payer: Cash Price |
$469.20
|
| Rate for Payer: Cigna Commercial |
$664.70
|
| Rate for Payer: First Health Commercial |
$703.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$703.80
|
| Rate for Payer: GEHA Commercial |
$547.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$703.80
|
| Rate for Payer: Multiplan All |
$711.62
|
| Rate for Payer: OMNI Networks Commercial |
$547.40
|
| Rate for Payer: One Health Plan PPO/POS |
$703.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$742.90
|
| Rate for Payer: Three Rivers Provider Network All |
$586.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$727.26
|
| Rate for Payer: Zelis Auto |
$312.80
|
|
|
IMPLT POL TRIA 4.8 X 24
|
Facility
|
IP
|
$782.00
|
|
|
Service Code
|
CPT C2617
|
| Hospital Charge Code |
7006796
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$312.80 |
| Max. Negotiated Rate |
$742.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$625.60
|
| Rate for Payer: Cash Price |
$469.20
|
| Rate for Payer: Cash Price |
$469.20
|
| Rate for Payer: Cigna Commercial |
$664.70
|
| Rate for Payer: First Health Commercial |
$703.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$703.80
|
| Rate for Payer: GEHA Commercial |
$547.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$703.80
|
| Rate for Payer: Multiplan All |
$711.62
|
| Rate for Payer: OMNI Networks Commercial |
$547.40
|
| Rate for Payer: One Health Plan PPO/POS |
$703.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$742.90
|
| Rate for Payer: Three Rivers Provider Network All |
$586.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$727.26
|
| Rate for Payer: Zelis Auto |
$312.80
|
|
|
IMPLT POL TRIA 4.8 X 24
|
Facility
|
OP
|
$782.00
|
|
|
Service Code
|
CPT C2617
|
| Hospital Charge Code |
7006796
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$195.50 |
| Max. Negotiated Rate |
$742.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$469.20
|
| Rate for Payer: Cash Price |
$469.20
|
| Rate for Payer: Cash Price |
$469.20
|
| Rate for Payer: Cigna Commercial |
$664.70
|
| Rate for Payer: First Health Commercial |
$703.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$703.80
|
| Rate for Payer: GEHA Commercial |
$625.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$703.80
|
| Rate for Payer: Humana ChoiceCare |
$203.32
|
| Rate for Payer: Multiplan All |
$711.62
|
| Rate for Payer: New Mexico Health Connections Medicare |
$469.20
|
| Rate for Payer: OMNI Networks Commercial |
$547.40
|
| Rate for Payer: One Health Plan PPO/POS |
$703.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$742.90
|
| Rate for Payer: Three Rivers Provider Network All |
$586.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$688.16
|
| Rate for Payer: United Healthcare Managed Medicaid |
$195.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$727.26
|
| Rate for Payer: Zelis Auto |
$312.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$391.00
|
|
|
IMPLT POL TRIA 4.8 X 26
|
Facility
|
OP
|
$782.00
|
|
|
Service Code
|
CPT C2617
|
| Hospital Charge Code |
7006797
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$195.50 |
| Max. Negotiated Rate |
$742.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$469.20
|
| Rate for Payer: Cash Price |
$469.20
|
| Rate for Payer: Cash Price |
$469.20
|
| Rate for Payer: Cigna Commercial |
$664.70
|
| Rate for Payer: First Health Commercial |
$703.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$703.80
|
| Rate for Payer: GEHA Commercial |
$625.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$703.80
|
| Rate for Payer: Humana ChoiceCare |
$203.32
|
| Rate for Payer: Multiplan All |
$711.62
|
| Rate for Payer: New Mexico Health Connections Medicare |
$469.20
|
| Rate for Payer: OMNI Networks Commercial |
$547.40
|
| Rate for Payer: One Health Plan PPO/POS |
$703.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$742.90
|
| Rate for Payer: Three Rivers Provider Network All |
$586.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$688.16
|
| Rate for Payer: United Healthcare Managed Medicaid |
$195.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$727.26
|
| Rate for Payer: Zelis Auto |
$312.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$391.00
|
|
|
IMPLT POL TRIA 4.8 X 26
|
Facility
|
IP
|
$782.00
|
|
|
Service Code
|
CPT C2617
|
| Hospital Charge Code |
7006797
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$312.80 |
| Max. Negotiated Rate |
$742.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$625.60
|
| Rate for Payer: Cash Price |
$469.20
|
| Rate for Payer: Cash Price |
$469.20
|
| Rate for Payer: Cigna Commercial |
$664.70
|
| Rate for Payer: First Health Commercial |
$703.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$703.80
|
| Rate for Payer: GEHA Commercial |
$547.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$703.80
|
| Rate for Payer: Multiplan All |
$711.62
|
| Rate for Payer: OMNI Networks Commercial |
$547.40
|
| Rate for Payer: One Health Plan PPO/POS |
$703.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$742.90
|
| Rate for Payer: Three Rivers Provider Network All |
$586.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$727.26
|
| Rate for Payer: Zelis Auto |
$312.80
|
|
|
IMPLT POL ULTRA 5FX16CM
|
Facility
|
IP
|
$782.00
|
|
|
Service Code
|
CPT C2617
|
| Hospital Charge Code |
7006629
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$312.80 |
| Max. Negotiated Rate |
$742.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$625.60
|
| Rate for Payer: Cash Price |
$469.20
|
| Rate for Payer: Cash Price |
$469.20
|
| Rate for Payer: Cigna Commercial |
$664.70
|
| Rate for Payer: First Health Commercial |
$703.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$703.80
|
| Rate for Payer: GEHA Commercial |
$547.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$703.80
|
| Rate for Payer: Multiplan All |
$711.62
|
| Rate for Payer: OMNI Networks Commercial |
$547.40
|
| Rate for Payer: One Health Plan PPO/POS |
$703.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$742.90
|
| Rate for Payer: Three Rivers Provider Network All |
$586.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$727.26
|
| Rate for Payer: Zelis Auto |
$312.80
|
|
|
IMPLT POL ULTRA 5FX16CM
|
Facility
|
OP
|
$782.00
|
|
|
Service Code
|
CPT C2617
|
| Hospital Charge Code |
7006629
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$195.50 |
| Max. Negotiated Rate |
$742.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$469.20
|
| Rate for Payer: Cash Price |
$469.20
|
| Rate for Payer: Cash Price |
$469.20
|
| Rate for Payer: Cigna Commercial |
$664.70
|
| Rate for Payer: First Health Commercial |
$703.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$703.80
|
| Rate for Payer: GEHA Commercial |
$625.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$703.80
|
| Rate for Payer: Humana ChoiceCare |
$203.32
|
| Rate for Payer: Multiplan All |
$711.62
|
| Rate for Payer: New Mexico Health Connections Medicare |
$469.20
|
| Rate for Payer: OMNI Networks Commercial |
$547.40
|
| Rate for Payer: One Health Plan PPO/POS |
$703.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$742.90
|
| Rate for Payer: Three Rivers Provider Network All |
$586.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$688.16
|
| Rate for Payer: United Healthcare Managed Medicaid |
$195.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$727.26
|
| Rate for Payer: Zelis Auto |
$312.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$391.00
|
|
|
IMPLT POL ULTRA 5FX18CM
|
Facility
|
OP
|
$782.00
|
|
|
Service Code
|
CPT C2617
|
| Hospital Charge Code |
7006630
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$195.50 |
| Max. Negotiated Rate |
$742.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$469.20
|
| Rate for Payer: Cash Price |
$469.20
|
| Rate for Payer: Cash Price |
$469.20
|
| Rate for Payer: Cigna Commercial |
$664.70
|
| Rate for Payer: First Health Commercial |
$703.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$703.80
|
| Rate for Payer: GEHA Commercial |
$625.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$703.80
|
| Rate for Payer: Humana ChoiceCare |
$203.32
|
| Rate for Payer: Multiplan All |
$711.62
|
| Rate for Payer: New Mexico Health Connections Medicare |
$469.20
|
| Rate for Payer: OMNI Networks Commercial |
$547.40
|
| Rate for Payer: One Health Plan PPO/POS |
$703.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$742.90
|
| Rate for Payer: Three Rivers Provider Network All |
$586.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$688.16
|
| Rate for Payer: United Healthcare Managed Medicaid |
$195.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$727.26
|
| Rate for Payer: Zelis Auto |
$312.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$391.00
|
|
|
IMPLT POL ULTRA 5FX18CM
|
Facility
|
IP
|
$782.00
|
|
|
Service Code
|
CPT C2617
|
| Hospital Charge Code |
7006630
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$312.80 |
| Max. Negotiated Rate |
$742.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$625.60
|
| Rate for Payer: Cash Price |
$469.20
|
| Rate for Payer: Cash Price |
$469.20
|
| Rate for Payer: Cigna Commercial |
$664.70
|
| Rate for Payer: First Health Commercial |
$703.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$703.80
|
| Rate for Payer: GEHA Commercial |
$547.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$703.80
|
| Rate for Payer: Multiplan All |
$711.62
|
| Rate for Payer: OMNI Networks Commercial |
$547.40
|
| Rate for Payer: One Health Plan PPO/POS |
$703.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$742.90
|
| Rate for Payer: Three Rivers Provider Network All |
$586.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$727.26
|
| Rate for Payer: Zelis Auto |
$312.80
|
|
|
IMPLT POL ULTRA 5FX22CM
|
Facility
|
OP
|
$929.00
|
|
|
Service Code
|
CPT C2617
|
| Hospital Charge Code |
7002448
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$232.25 |
| Max. Negotiated Rate |
$882.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$557.40
|
| Rate for Payer: Cash Price |
$557.40
|
| Rate for Payer: Cash Price |
$557.40
|
| Rate for Payer: Cigna Commercial |
$789.65
|
| Rate for Payer: First Health Commercial |
$836.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$836.10
|
| Rate for Payer: GEHA Commercial |
$743.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$836.10
|
| Rate for Payer: Humana ChoiceCare |
$241.54
|
| Rate for Payer: Multiplan All |
$845.39
|
| Rate for Payer: New Mexico Health Connections Medicare |
$557.40
|
| Rate for Payer: OMNI Networks Commercial |
$650.30
|
| Rate for Payer: One Health Plan PPO/POS |
$836.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$882.55
|
| Rate for Payer: Three Rivers Provider Network All |
$696.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$817.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$232.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$863.97
|
| Rate for Payer: Zelis Auto |
$371.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$464.50
|
|
|
IMPLT POL ULTRA 5FX22CM
|
Facility
|
IP
|
$929.00
|
|
|
Service Code
|
CPT C2617
|
| Hospital Charge Code |
7002448
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$371.60 |
| Max. Negotiated Rate |
$882.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$743.20
|
| Rate for Payer: Cash Price |
$557.40
|
| Rate for Payer: Cash Price |
$557.40
|
| Rate for Payer: Cigna Commercial |
$789.65
|
| Rate for Payer: First Health Commercial |
$836.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$836.10
|
| Rate for Payer: GEHA Commercial |
$650.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$836.10
|
| Rate for Payer: Multiplan All |
$845.39
|
| Rate for Payer: OMNI Networks Commercial |
$650.30
|
| Rate for Payer: One Health Plan PPO/POS |
$836.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$882.55
|
| Rate for Payer: Three Rivers Provider Network All |
$696.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$863.97
|
| Rate for Payer: Zelis Auto |
$371.60
|
|
|
IMPLT POL ULTRA 6FX22CM
|
Facility
|
OP
|
$929.00
|
|
|
Service Code
|
CPT C2617
|
| Hospital Charge Code |
7002429
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$232.25 |
| Max. Negotiated Rate |
$882.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$557.40
|
| Rate for Payer: Cash Price |
$557.40
|
| Rate for Payer: Cash Price |
$557.40
|
| Rate for Payer: Cigna Commercial |
$789.65
|
| Rate for Payer: First Health Commercial |
$836.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$836.10
|
| Rate for Payer: GEHA Commercial |
$743.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$836.10
|
| Rate for Payer: Humana ChoiceCare |
$241.54
|
| Rate for Payer: Multiplan All |
$845.39
|
| Rate for Payer: New Mexico Health Connections Medicare |
$557.40
|
| Rate for Payer: OMNI Networks Commercial |
$650.30
|
| Rate for Payer: One Health Plan PPO/POS |
$836.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$882.55
|
| Rate for Payer: Three Rivers Provider Network All |
$696.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$817.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$232.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$863.97
|
| Rate for Payer: Zelis Auto |
$371.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$464.50
|
|
|
IMPLT POL ULTRA 6FX22CM
|
Facility
|
IP
|
$929.00
|
|
|
Service Code
|
CPT C2617
|
| Hospital Charge Code |
7002429
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$371.60 |
| Max. Negotiated Rate |
$882.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$743.20
|
| Rate for Payer: Cash Price |
$557.40
|
| Rate for Payer: Cash Price |
$557.40
|
| Rate for Payer: Cigna Commercial |
$789.65
|
| Rate for Payer: First Health Commercial |
$836.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$836.10
|
| Rate for Payer: GEHA Commercial |
$650.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$836.10
|
| Rate for Payer: Multiplan All |
$845.39
|
| Rate for Payer: OMNI Networks Commercial |
$650.30
|
| Rate for Payer: One Health Plan PPO/POS |
$836.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$882.55
|
| Rate for Payer: Three Rivers Provider Network All |
$696.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$863.97
|
| Rate for Payer: Zelis Auto |
$371.60
|
|
|
IMPLT POL ULTRA 6FX24CM
|
Facility
|
IP
|
$859.00
|
|
|
Service Code
|
CPT C2617
|
| Hospital Charge Code |
7002430
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$343.60 |
| Max. Negotiated Rate |
$816.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$687.20
|
| Rate for Payer: Cash Price |
$515.40
|
| Rate for Payer: Cash Price |
$515.40
|
| Rate for Payer: Cigna Commercial |
$730.15
|
| Rate for Payer: First Health Commercial |
$773.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$773.10
|
| Rate for Payer: GEHA Commercial |
$601.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$773.10
|
| Rate for Payer: Multiplan All |
$781.69
|
| Rate for Payer: OMNI Networks Commercial |
$601.30
|
| Rate for Payer: One Health Plan PPO/POS |
$773.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$816.05
|
| Rate for Payer: Three Rivers Provider Network All |
$644.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$798.87
|
| Rate for Payer: Zelis Auto |
$343.60
|
|
|
IMPLT POL ULTRA 6FX24CM
|
Facility
|
OP
|
$859.00
|
|
|
Service Code
|
CPT C2617
|
| Hospital Charge Code |
7002430
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$214.75 |
| Max. Negotiated Rate |
$816.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$515.40
|
| Rate for Payer: Cash Price |
$515.40
|
| Rate for Payer: Cash Price |
$515.40
|
| Rate for Payer: Cigna Commercial |
$730.15
|
| Rate for Payer: First Health Commercial |
$773.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$773.10
|
| Rate for Payer: GEHA Commercial |
$687.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$773.10
|
| Rate for Payer: Humana ChoiceCare |
$223.34
|
| Rate for Payer: Multiplan All |
$781.69
|
| Rate for Payer: New Mexico Health Connections Medicare |
$515.40
|
| Rate for Payer: OMNI Networks Commercial |
$601.30
|
| Rate for Payer: One Health Plan PPO/POS |
$773.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$816.05
|
| Rate for Payer: Three Rivers Provider Network All |
$644.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$755.92
|
| Rate for Payer: United Healthcare Managed Medicaid |
$214.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$798.87
|
| Rate for Payer: Zelis Auto |
$343.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$429.50
|
|
|
IMPLT POL ULTRA 6FX26CM
|
Facility
|
OP
|
$859.00
|
|
|
Service Code
|
CPT C2617
|
| Hospital Charge Code |
7002446
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$214.75 |
| Max. Negotiated Rate |
$816.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$515.40
|
| Rate for Payer: Cash Price |
$515.40
|
| Rate for Payer: Cash Price |
$515.40
|
| Rate for Payer: Cigna Commercial |
$730.15
|
| Rate for Payer: First Health Commercial |
$773.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$773.10
|
| Rate for Payer: GEHA Commercial |
$687.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$773.10
|
| Rate for Payer: Humana ChoiceCare |
$223.34
|
| Rate for Payer: Multiplan All |
$781.69
|
| Rate for Payer: New Mexico Health Connections Medicare |
$515.40
|
| Rate for Payer: OMNI Networks Commercial |
$601.30
|
| Rate for Payer: One Health Plan PPO/POS |
$773.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$816.05
|
| Rate for Payer: Three Rivers Provider Network All |
$644.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$755.92
|
| Rate for Payer: United Healthcare Managed Medicaid |
$214.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$798.87
|
| Rate for Payer: Zelis Auto |
$343.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$429.50
|
|
|
IMPLT POL ULTRA 6FX26CM
|
Facility
|
IP
|
$859.00
|
|
|
Service Code
|
CPT C2617
|
| Hospital Charge Code |
7002446
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$343.60 |
| Max. Negotiated Rate |
$816.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$687.20
|
| Rate for Payer: Cash Price |
$515.40
|
| Rate for Payer: Cash Price |
$515.40
|
| Rate for Payer: Cigna Commercial |
$730.15
|
| Rate for Payer: First Health Commercial |
$773.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$773.10
|
| Rate for Payer: GEHA Commercial |
$601.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$773.10
|
| Rate for Payer: Multiplan All |
$781.69
|
| Rate for Payer: OMNI Networks Commercial |
$601.30
|
| Rate for Payer: One Health Plan PPO/POS |
$773.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$816.05
|
| Rate for Payer: Three Rivers Provider Network All |
$644.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$798.87
|
| Rate for Payer: Zelis Auto |
$343.60
|
|
|
IMPLT POL ULTRA 6FX28CM
|
Facility
|
IP
|
$859.00
|
|
|
Service Code
|
CPT C2617
|
| Hospital Charge Code |
7002447
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$343.60 |
| Max. Negotiated Rate |
$816.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$687.20
|
| Rate for Payer: Cash Price |
$515.40
|
| Rate for Payer: Cash Price |
$515.40
|
| Rate for Payer: Cigna Commercial |
$730.15
|
| Rate for Payer: First Health Commercial |
$773.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$773.10
|
| Rate for Payer: GEHA Commercial |
$601.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$773.10
|
| Rate for Payer: Multiplan All |
$781.69
|
| Rate for Payer: OMNI Networks Commercial |
$601.30
|
| Rate for Payer: One Health Plan PPO/POS |
$773.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$816.05
|
| Rate for Payer: Three Rivers Provider Network All |
$644.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$798.87
|
| Rate for Payer: Zelis Auto |
$343.60
|
|
|
IMPLT POL ULTRA 6FX28CM
|
Facility
|
OP
|
$859.00
|
|
|
Service Code
|
CPT C2617
|
| Hospital Charge Code |
7002447
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$214.75 |
| Max. Negotiated Rate |
$816.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$515.40
|
| Rate for Payer: Cash Price |
$515.40
|
| Rate for Payer: Cash Price |
$515.40
|
| Rate for Payer: Cigna Commercial |
$730.15
|
| Rate for Payer: First Health Commercial |
$773.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$773.10
|
| Rate for Payer: GEHA Commercial |
$687.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$773.10
|
| Rate for Payer: Humana ChoiceCare |
$223.34
|
| Rate for Payer: Multiplan All |
$781.69
|
| Rate for Payer: New Mexico Health Connections Medicare |
$515.40
|
| Rate for Payer: OMNI Networks Commercial |
$601.30
|
| Rate for Payer: One Health Plan PPO/POS |
$773.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$816.05
|
| Rate for Payer: Three Rivers Provider Network All |
$644.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$755.92
|
| Rate for Payer: United Healthcare Managed Medicaid |
$214.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$798.87
|
| Rate for Payer: Zelis Auto |
$343.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$429.50
|
|
|
IMPLT POL ULTRA 7FX20CM
|
Facility
|
OP
|
$782.00
|
|
|
Service Code
|
CPT C2617
|
| Hospital Charge Code |
7006726
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$195.50 |
| Max. Negotiated Rate |
$742.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$469.20
|
| Rate for Payer: Cash Price |
$469.20
|
| Rate for Payer: Cash Price |
$469.20
|
| Rate for Payer: Cigna Commercial |
$664.70
|
| Rate for Payer: First Health Commercial |
$703.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$703.80
|
| Rate for Payer: GEHA Commercial |
$625.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$703.80
|
| Rate for Payer: Humana ChoiceCare |
$203.32
|
| Rate for Payer: Multiplan All |
$711.62
|
| Rate for Payer: New Mexico Health Connections Medicare |
$469.20
|
| Rate for Payer: OMNI Networks Commercial |
$547.40
|
| Rate for Payer: One Health Plan PPO/POS |
$703.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$742.90
|
| Rate for Payer: Three Rivers Provider Network All |
$586.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$688.16
|
| Rate for Payer: United Healthcare Managed Medicaid |
$195.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$727.26
|
| Rate for Payer: Zelis Auto |
$312.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$391.00
|
|
|
IMPLT POL ULTRA 7FX20CM
|
Facility
|
IP
|
$782.00
|
|
|
Service Code
|
CPT C2617
|
| Hospital Charge Code |
7006726
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$312.80 |
| Max. Negotiated Rate |
$742.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$625.60
|
| Rate for Payer: Cash Price |
$469.20
|
| Rate for Payer: Cash Price |
$469.20
|
| Rate for Payer: Cigna Commercial |
$664.70
|
| Rate for Payer: First Health Commercial |
$703.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$703.80
|
| Rate for Payer: GEHA Commercial |
$547.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$703.80
|
| Rate for Payer: Multiplan All |
$711.62
|
| Rate for Payer: OMNI Networks Commercial |
$547.40
|
| Rate for Payer: One Health Plan PPO/POS |
$703.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$742.90
|
| Rate for Payer: Three Rivers Provider Network All |
$586.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$727.26
|
| Rate for Payer: Zelis Auto |
$312.80
|
|
|
IMPLT POL ULTRA 7FX22CM
|
Facility
|
IP
|
$782.00
|
|
|
Service Code
|
CPT C2617
|
| Hospital Charge Code |
7006727
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$312.80 |
| Max. Negotiated Rate |
$742.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$625.60
|
| Rate for Payer: Cash Price |
$469.20
|
| Rate for Payer: Cash Price |
$469.20
|
| Rate for Payer: Cigna Commercial |
$664.70
|
| Rate for Payer: First Health Commercial |
$703.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$703.80
|
| Rate for Payer: GEHA Commercial |
$547.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$703.80
|
| Rate for Payer: Multiplan All |
$711.62
|
| Rate for Payer: OMNI Networks Commercial |
$547.40
|
| Rate for Payer: One Health Plan PPO/POS |
$703.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$742.90
|
| Rate for Payer: Three Rivers Provider Network All |
$586.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$727.26
|
| Rate for Payer: Zelis Auto |
$312.80
|
|
|
IMPLT POL ULTRA 7FX22CM
|
Facility
|
OP
|
$782.00
|
|
|
Service Code
|
CPT C2617
|
| Hospital Charge Code |
7006727
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$195.50 |
| Max. Negotiated Rate |
$742.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$469.20
|
| Rate for Payer: Cash Price |
$469.20
|
| Rate for Payer: Cash Price |
$469.20
|
| Rate for Payer: Cigna Commercial |
$664.70
|
| Rate for Payer: First Health Commercial |
$703.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$703.80
|
| Rate for Payer: GEHA Commercial |
$625.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$703.80
|
| Rate for Payer: Humana ChoiceCare |
$203.32
|
| Rate for Payer: Multiplan All |
$711.62
|
| Rate for Payer: New Mexico Health Connections Medicare |
$469.20
|
| Rate for Payer: OMNI Networks Commercial |
$547.40
|
| Rate for Payer: One Health Plan PPO/POS |
$703.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$742.90
|
| Rate for Payer: Three Rivers Provider Network All |
$586.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$688.16
|
| Rate for Payer: United Healthcare Managed Medicaid |
$195.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$727.26
|
| Rate for Payer: Zelis Auto |
$312.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$391.00
|
|
|
IMPLT POL ULTRA 7FX24CM
|
Facility
|
OP
|
$782.00
|
|
|
Service Code
|
CPT C2617
|
| Hospital Charge Code |
7006728
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$195.50 |
| Max. Negotiated Rate |
$742.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$469.20
|
| Rate for Payer: Cash Price |
$469.20
|
| Rate for Payer: Cash Price |
$469.20
|
| Rate for Payer: Cigna Commercial |
$664.70
|
| Rate for Payer: First Health Commercial |
$703.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$703.80
|
| Rate for Payer: GEHA Commercial |
$625.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$703.80
|
| Rate for Payer: Humana ChoiceCare |
$203.32
|
| Rate for Payer: Multiplan All |
$711.62
|
| Rate for Payer: New Mexico Health Connections Medicare |
$469.20
|
| Rate for Payer: OMNI Networks Commercial |
$547.40
|
| Rate for Payer: One Health Plan PPO/POS |
$703.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$742.90
|
| Rate for Payer: Three Rivers Provider Network All |
$586.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$688.16
|
| Rate for Payer: United Healthcare Managed Medicaid |
$195.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$727.26
|
| Rate for Payer: Zelis Auto |
$312.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$391.00
|
|
